Out of this World

I'm on MOD-2 for 13 shifts, and in the middle of my fourth shift--they run from 8pm to 8am--and reminded of a bumper sticker I saw last year which I am modifying for this rotation: "Worst. Rotation. Ever."

But, that is not the entire reason I'm writing now (from work in the hour and a half before I start admitting from the ER). The reason I'm writing now is because the supposed "lupus cerebritis" (but really psychotic) new admit needed a lumbar puncture and I was helping Charlene (my intern from the ICU last month) while her supervising resident admitted another patient with her other intern. Seemed normal enough. To start.

Charlene tried the lumbar puncture a couple times, as I'm standing there all gowned up in our sterile blue garb. Of course I had to find an extra head cover because the patient wanted the one in the sterile kit (first clue of impending crazy?). She asked me if I could try next. I sterilly move the table out of the way, the bed was high up in the air so I didn't have to bend over as much; I re-evaluate the landmarks and re-direct the needle to try to slide it in between the vertebrae to get the cerebral spinal fluid. I hit bone and redirect again.

During this time, I reassure the patient that she is doing well. She is courteous and says, "thank you." Then the tenor of her conversation changed, "I have to go. We're going to be late for the party. It's 11pm and we need to go. You need to finish this procedure." I'm trying to concentrate on getting the fluid, and reassure her and ask her to stay still and remind her she has a needle in her back. And then she says, "I'm leaving. I'm going to go." In the split second while I try to decide if she's serious, she sits up and begins grabbing her personal items. I pull the needle out of her back just in the nick of time. Blood starts streaming down her back where it had been jostled by her movement. Fortunately, she wears only the blue bouffant cap, an untied hospital gown, and Depends (which catch the dripping blood), so her clothes are spared.

When she grabs her stuff, she also grabs Charlene's white coat and pulls out Charlene's phone, books and papers from that night's work out of the pockets. "Ma'am, that is my coat," Charlene is calmly reminding her as the patient yanks it back toward herself, "No it isn't! It's mine. I bought it." The nurses threaten to call security and try to reason with her (though she's entirely unreasonable). She's out of bed now and Charlene tries to pull her coat from her and they struggle back and forth in the 6-bed hospital room. Then the patient takes a swing at her, gouging Charlene's hand with her finger nails, and Charlene lets go of the coat.

She storms out of the room muttering nonsense as her 72 year old mother gets out of the way (she's been through this before and sometimes has to lock herself in her car when her 40 year old daughter gets out of hand at home). With blood dripping down her back making a red stain on her white Depends, she makes a bee-line for the elevator. "Someone has to stop her," her mother says defeatedly as we stand there and watch her go, afraid to get into an altercation with her.

Security comes up the other set of elevators after she's already taken the main elevators down, "What's going on?" they ask a little late. We explain. "Is she on a hold?" This means has psych or the ED placed a "psych hold" on her meaning that we can hold her against her will for the protection of herself or others. She is not on a hold. Yet. We page psych and the ER to see who can place one on her fastest and send security after her.

Then we wait.

We wait.

Where is she?

Her mom is concerned, but calm. Charlene wants her coat back. We bandage up her wounds. I'm still a little stunned and ask Charlene how badly her team wanted this LP. Not bad enough to try again. We order haldol to have on hold for when (if?) she is returned.

She is. Three security guards escort her down the hall (now in a wheelchair), still clutching her personal belongings and Charlene's white coat. They tell us they found her at the outpatient clinic a block away and mention that she had blood dripping down her back. They also come up to Charlene and tell her the patient had her badge also, in a somewhat accusatory tone.

The patient has calmed down, apologizing even, but making no sense, "How do they get her into the galactaca when it is all round without windows?" And when we asked her if we could put a bandage on her back, she said, "No, I'm just going to let it bleed for a while." And then when she's all tucked back into bed, she asks, "What does combative mean?"

Charlene's got it under control for now. I return upstairs to relate the saga to the rest of the on-call team and Mark, the night float intern, and continue coveting a root beer float until the cafeteria opens at 11:30 pm. Mark says I should have taken pictures during the coat tug-of-war. He's even willing to reenact it with Charlene. But we settle for a computer stick figure picture for the time being.

O O
{ X ]
/\ /\

1123

The next day he was still alive, but barely. Barely. They'd moved him up to the 11th floor and something told me right away that he would be in the room I'd been in two years prior.

He was. I learned that his housekeeper and her daughter had come to see him that night after I'd left. She held his and and said his name, disbelievingly.

I went to see him upstairs. He was no longer responsive at all. He breathed a scant 8 times her minute with his mouth gaping open and his body arching back with each painfully deep breath. He's alone in the room. The view is the same as I stared at for days and day. The pictures are the same. No flowers for him, where I had several bunches. They've taken the night stand out, also. He has no need for it.

His bag of personal items in on the chair next to the bed. His wallet is there. I look at his drivers' license picture and he looks sad in it. Healthier, but still sad. He has the card with the mortuary on it. He's made all the arrangements and written on the back the phone number "to call in case of my death." It made me feel a little more at peace that he'd done that, for some reason. He wanted his housekeeper to have his valuables. He had a few rings and bracelets that he must have been wearing when he was brought in originally. His clothes were old, but clean and neat.

He felt warm when I held his hand again.

I went back downstairs to the rest of our sick patients. We rounded on them and saved him for last. By the time, the intern, fellow, and I got there, I looked at him from the door. No more of the gasping breaths. No more breaths. "He's gone," I said.

We walked in. I took his hand. He was still warm. Charlene pronounced his time of death. Tears rolled down my cheeks and she asked if I was okay, "It's just sad." Just sad.

Not Forgotten

He's probably dying right now.  He was breathing in the teens--comfortably for the first time in days and the morphine drip had been turned up to 10.  They said he was unresponsive but when I went in to hold his hand and say his name and tell him to relax and everything was okay, he opened his eyes.  I stood with him for a while, watching out the window, thinking how sad it is to die alone.  They only person he had was his housekeeper and he didn't want us to call her.  When Julie, the nurse, tried anyway, no one answered.  He was breathing with a face mask now.  He'd been grumpy since I'd admitted him a week before.  At first he had a head bleed from taking too much coumadin (or at least his INR was too high at 9.8) and had bled into an unusual spot in his head that neurology thought might be a metastases from an undiscovered cancer.  I went in to visit him even after I'd transferred him to the neurology service.  Once day I went in and he was sitting at the side of his bed with his head bent down over his bedside table.  I said hello and asked him how he was feeling.  He told me to wait a minute.  I thought he had questions for his medical team so I told him I was only visiting now and the neurologists were his doctors.  "Just wait a minute.  We can talk."  I felt bad.  He'd only wanted company, which is what I wanted to be, but I didn't understand.  He didn't really have much to say.  I stood there and held his hand for a minute before he shooed me off, "Okay, you can go now.  I'm going to meditate."  

Ali surprised me with a visit on that first night when I admitted him with the head bleed. He was sitting outside the room after I visited Mr. M. and he'd curtly dismissed me, telling me he wanted to sleep.  Mr. M. was grumpy.  He wanted to be left alone, "I'm fine!"  He softened up a little.  He'd been having trouble breathing for at least a month, he told me, but today he had weakness on his face that was new--"heaviness actually."  He came in because he was worried he'd had a stroke.  When the head bleed showed up on the CT and his INR came back at 9.8, likely from taking too much coumadin, a grilled him about his diet and his activities.  He didn't shop.  He didn't eat well.  That last month he could barely walk around his apartment without getting short of breath.  He'd been to the coumadin clinic 1 month before and always on time for the past three years and his INR has always been in the right range--until now.  

It wasn't until a couple nights later when Ali and I started talking some how about how many older people who are lonely commit suicide by either taking too many pills or exacerbating their medical conditions on purpose that I wondered if Mr. M. had done that.  He insisted to me that he'd taken the right amount, recited his doses to me correctly and everything, "Five on weekday and seven mg on Sundays."  He looked irritated and disheartened when I told him I thought it was the medicine that had done this to him.  He seemed shocked.  

When I first saw him in the ER he didn't even want to talk to me because so many people had already asked him a million questions.  I told him I'd wait and we could see him upstairs.  The neurosurgeons wanted "neuro checks" every hour all night.  Wake up, open your eyes, have a bright light shone in both of them, move your hands and feet.  Go back to sleep and repeat every hour.  (I remembered my neuro checks every four hours when I was a patient and even that was horrible.   Every single hour.  There's no way he slept much those first few days he was there.)  I asked him if he felt depressed.  He did.  He lived alone and had no family.  Had been married once, but wasn't now and didn't seem to want to talk about it so I dropped the subject.  Had no children.  

He did fine in the ICU and I transferred him out the next day.  I almost sent him to the medicine team, but on second thought I figured it should be neurology to watch over him since his head bleed and his new kepra dosing was his main concern.  Though he had so many medical problems that I knew they couldn't handle well that I hesitated.  His COPD was "end stage" with an FEV1 of 1.47.  His heart failure on his new echocardiogram had progressed to "severe diastolic disease."  His atrial fibrillation was uncontrolled since we'd stopped his medicine for it because of his new low blood pressure.  His coronary artery disease had necessitated a coronary artery bypass graft a few years before.  His legs were almost black from decreased blood flow related to his peripheral vascular disease.  His chronic kidney disease had acute kidney injury stacked on top of it since he hadn't been eating or drinking well and since his volume status was a fine balancing act with his heart barely able to pump any more.  

On the neurology service, they started him on an antidepressant and got a medicine consult to follow him (unfortunately not one of our most stellar attendings was on consults at that time).  They didn't restart his home medications and they gave him more fluid than his heart could handle so a lot of in ended up in his lungs, making it harder and harder for him to breath.  He may also have been aspirating some of his food and developed pneumonia in the interim.  

He transferred off our service after about 12 hours and out of the ICU the next morning.  I had the next day off but was worried about him so followed along as much as I could on the computer from home.  After a couple days I didn't hear about him until one of the traveling nurses who worked in the ICU also came to find me since neither the neuro intern nor attending had paged her back for three hours, during which time she'd called a rapid response o him because he was working terribly hard to breath and his PO2 on his blood gas was 45 and he was in afib and tachycardic and hypotensive.  She came to find me just as I was having anesthesia intubate another patient in the other step-d0wn unit, "Can you come see Mr. M.?  I can't get in touch with his team."  He looked terrible when I got there.  I ordered a few things and then asked him if he remembered me and how he was feeling.  He remembered me, and though his breathing was very labored he said he felt fine, in very short sentences.  

I paged the neuro intern again, signing it "ICU resident" and he called back at last.  When I told him how sick his patient was he said he'd be there in 10 minutes--and he'd called from an outside line though he was supposed to be in house.  My worry for Mr. M. mixed with my irritation about the lack of recognition about how sick and fragile he was.  I told him what to do and cleared a bed for Mr. M. in the ICU again (the same bed he'd had before--the one with an ocean view where you could see downtown and the airplanes fly in and out).  But the neuro intern didn't say anything about moving him.  I called him shortly after and got a little more stern, saying that he at least needed to let his attending know how sick he is and strongly suggesting that he be trasnferred to at least a medicine team and probably back to the ICU (me).  "Oh. Okay.  Yeah.  Thanks.  Sure.  I'll call him."  I'm sure they do a much better job with all the stuff above the neck than I do, but at the very least he needed to know when to ask for help.  And though I very rarely make a fuss, I fussed at him quite a bit about needing to respond to pages and recognize when his patients get much worse.  

Soon after I got a page saying his attending "would be happy to transfer him to wherever I thought most appropriate."  Good thing since I'd all but finished the transfer orders already. 

That whole night, I tried not to intubate him.  His COPD was so bad I thought he'd never get off the ventilator if I put him on it.  He didn't want the BiPAP mask (though he agreed to it by the next morning) so we fiddled around with face masks and nonrebreathers and oximeters and the like.  I diuresed all the extra fluid I could off of him with a bumex drip and diuril.  I controlled his out of control heart rate with a continuous infusion of a diltiazem, a rate controlling medication.  His blood gas didn't get better, but it didn't get worse either.  The fellow that night gave him a 50/50 chance of being intubated by morning.  We made it through the night, though. 

When I went to say bye to him that morning, I told him I had the next day off but would be back on Wednesday (today) and that I wanted to see him without a tube down his throat.  

He was already telling the nurses every morning, "I'm going to die today."  Of course yesterday he said it more non-chalantly.  Today he was more serious.

One of the interns was going to round on him this morning, but I told him I wanted to instead.  He looked no better, but also no worse.  He still worked hard to breath and that couldn't last forever.  We decided to put an arterial line in him on rounds and by the time we got around to doing it, the results were terrible, pH had gone from 7.37 to 7.19.  Not good.  And while he'd been more of his cantankerous self the day before and even this morning, he was no longer saying he felt fine.  "How's your breathing, Raymond?"  "Not so good," he gasped.  

Neal, the intern, talked to him about wanted a tube to help him breath.  He shook his head, "no," no longer able to talk much for lack of breath.  "Do you understand that you might die without one?"  He nodded.  "Open your eyes, Raymond!  I need to make sure you understand this."  And he repeated the same questions in different phrases.  The answers were the same.  My eyes welled up as suddenly I flashed into his acidotic mind and wondered how it would feel to have someone ask you if you understood that you probably would die--very soon. And die without anyone except people you'd met seven days ago.  Like your life had been a blip on a screen that was about to go out and no one would even remember you.  No one, except perhaps your cleaning lady and her daughter, would even know that you were gone.  And who knows if they would care.

The day before he'd met with social work and had been very anxious about being able to pay his rent by June 1st or he would lose his apartment.  He also worried that if he died his cleaning lady, Rosarita, had only three days to clean out what she wanted from his apartment where he's lived alone for 15 years, before everything else went to the Salvation Army.  He'd fretted about it since before he transferred back to the ICU.  On the day when the nurse came to tell me he was breathing so badly, she told me he'd made her look in his wallet and get the card for a mortuary that he carried there.  And get the card for his house-keeper to tell her to make sure to clean out his apartment within three days of his death.  

It was as if his life would just blow away with the ocean breeze, as if he'd rustled around with the leaves for a few days and then...gone.  Nothing left.  Things he'd known and recognized and used daily given away.  Maybe items he's saved or treasured left without stories or context or care, with no one to remember or know.  

I wondered what he thought as he drifted off into that morphine-induced haze as I held his hand and stroked his hair and tried to imagine what his life might have been like, or what he'd wanted it to be like.  If he'd had regrets.  If he'd pictured his end differently.  If there was someone he'd love who he wished were there instead of me.  He still opened his eyes when I called his name, "Raymond," the muscles above his eyes flickered and his eyelids rolled slowly up and his eyes moved to focus on me briefly, "It's me.  Everything is okay.  You're doing great.  Just relax now."  That morning he'd told us he was fine and that he needed a shave and a haircut.  It was hard to understand him through the mask and he'd had to repeat the "shave" part a few times and got irritated.  

I looked at his salt and pepper stubble under the oxygen mask and wished we could shave him while he still had any connection with this world.  Julie rubbed his face with a warm washcloth over his eye lids and his forehead and his hair and his dry lips sucking in numbered breaths.  The scar across his chest reminded me of his CABG a few years before and I wondered who had helped him recover from that.  Or who had gotten him to his coumadin appointments or to his doctor's appointment with one of my co-residents.  I remembered Pop had had a CABG too, and I'd come home to take care of him.  My hands were colder than Raymond's, but I knew they wouldn't be for long.  I squeezed his hand and rubbed his shoulder and looked at the liquid drip into his veins.  His arterial line was oozing and when I moved my hand away there was a puddle of serous fluid in his palm.  I was surprised each time I returned and his hands felt so warm.  

His heart rate had slowed way down, despite us turning off both rate-controlling medications. His blood pressure was low again.  His O2 sat was 92%.  I watched his heart monitor flutter around 66-62-60-58-59-58-57.  When you don't get enough oxygen and your most recent blood gas shows that your pH is 7.10, your heart doesn't work well.  Your body is tired.

I remember now what I said at Pop's service, that he was tired and it was time.  

And maybe it is time.  I fretted and went back and forth with his intubation with the attending earlier, knowing that I could convince him to get the tube in in throat and that on the ventilator I could fix his blood gas. But I couldn't fix his lung disease, or his heart disease, or his kidney disease, or his loneliness.  The most I could do was prolong this inevitable thing that may have taken him even as I have been writing.  And he may do to a nursing home or a "rehab" facility which the fellow, who did moonlighting there, said was "a fate worse than death."  I knew Raymond was tired, too, and that he felt tired, and sad, and frustrated and alone.  I supposed he was ready, "Do you understand that you might die?" Neal yelled at him as we tend to do with those who are very sick.  He nodded.  

I fought back tears as I held his hand and looked out his window, thinking of my med student's patient who had died a couple years before at the VA and her asking me if I'd been there when he died.  I hadn't.  The nurses called when he was almost gone, but I didn't want to see the end and he'd been in a coma all day.  

All I could do now for Raymond was bear witness to his candle flickering out.  I could make him comfotable so his last breaths weren't agonal.  I went to the bathroom and came back to say goodbye to him, "Just relax," his eyes flickered again and I placed my other hand over his heart feeling it beat, still warm, in his scared chest, "Everything is okay.  I'll see you soon.  You're doing great." I squeezed his hand and asked Julie, who was now doing her charting in his room instead of outside where the nurses usually sat to keep his respiratory rate below 30--to keep him comfortable.  She said she'd thought he would go faster once we'd started the morphine drip, but she wanted to not let him die alone.

As I waited to talk to her before I left, they moved his 84 year old neighbor out in a body bag.  He'd come in the night before after being found on the floor of his apartment covered in flies and feces when the management came in to see if the fire alarm was still working--so dehydrated his tongue was retracted back into his throat.  His leg was dead with dry gangrene and by the morning when I came in his arm, too, was cold and pulseless.  And while he'd been report-ably able to nod appropriately in the ER, he was no longer waking up at all even though we'd turned off the sedation hours before.  I cringe to think that his last days were spent alone on the floor of his apartment like that.  I cringe and I cry.  I'd tried to find any family or friends of his that morning, but he'd only listed the security guard at the place where he had lived five years ago, a man who remembered him but had only had casual small conversations with him and knew of no family or friends.  Every year after that when he'd renewed his lease, his apartment manager had said he'd left that line on the form blank.  "No family or emergency contacts listed."  Not a single soul to call or care or even know that he's gone.  No one to claim the body.  No one to know.  

Perhaps they have both touched people in their lives who will remember them.  Perhaps Raymond was grouchy always and drove people away.  Perhaps the other patient, who his landlady called, "a sweet man," did not remember those last horrible days, but some good day.  Maybe a day he spent in the woods or at the beach with someone he once loved.  Or maybe a day spent alone but with that unreasonable happiness that has no explanation except that it is.  Maybe Raymond is glad he is not dying alone.  Maybe he's glad to be going.  And maybe he's going somewhere more hopeful where he can breath easily and his heart can beat strong again and he can walk on feet that done constantly ache.  My fellow said she doesn't know how people can do this job without some sort of belief in a higher power and some place after.  

I don't always know what I believe, but as I placed my hand over his heart and said goodbye, I said to myself, "May God bless you and keep you."  May he indeed.  In a way that mankind has not blessed or kept you.  And in a way you have not been able, perhaps to bless and keep yourself.  

When Raymond came in that first night, grouchy as ever, I'd asked him what he liked to do and if he had any friends.  "No, I don't talk to people much.  I'm a thinker.  I like to think.  I like plays and opera.  I'm deep.  I never finished more than eighth grade, but I like real conversation.  I don't watch that trashy TV.  I read books."  I pictured him then in his apartment, alone, thinking about ideas he didn't or couldn't express.  I wondered how he'd watched opera or if he really had or just wanted to.  "I'm deep!" he'd insisted to me, as if he still has something to prove.  

But he had no more time to prove anything.  Or maybe he did.  Maybe that it really was his time to die, and those cards he carried around in his wallet and his worry about his house-keeper cleaning out his apartment said that he was ready.  Maybe he proved again to me that sometimes it is okay to go.  Maybe even that it is okay to go alone, if that's what you want.  Maybe that this grief of his solitude that we have imposed on him is akin to the pity he disdained.  Yet, still I believe that holding his hand and a wet washcloth on his face and a stroke of his hair felt good,  and felt like someone on this earth cared enough to make it okay for him to go on to the next.  

All he'd wanted to eat on his meal tray the day before was the vanilla pudding.  Julie said he'd scarfed it down.  Today we got him more vanilla pudding.  It was all he wanted to eat.   That and a milkshake.  Two puddings and an Ensure (the closest we could find) sat unfinished on his bedside table.

You see, Raymond, you are not forgotten.  Now at least someone will remember that you liked vanilla pudding.  And that you liked opera.  And that you meditated.  And that you liked to think.  And that you were tired and ready to move on.  I may not know your whole life, except what I imagine, but these things I know.  You are not forgotten.  Even as I picture you barking, "Forget me!  Leave me alone.  That's what I want." 

Is it?

Expiring

"Doctor, I do have one more question:  Can I kiss her?"  He asked the intern as I stood off to the side.  Neither of us had ever met this strong and kind-appearing man in jeans and a brown plaid shirt.  We'd only spoken with him on the phone several times that night.  Each time with worse news.  Matt, a bright and kind intern, had called him to consent for an arterial line when her blood pressure was dropping into the realm of other worlds.  He'd spoken with him about his wife's state.  He'd done everything he could with the two small peripheral intravenous catheters that he could.  He'd called me when she needed intravenous medications to keep her blood circulating.  Medications that usually have to run through a more invasive central venous line--medications you only can use in the ICU.  

I'd met her two days before.  But she'd died two months before I'd met her I later discovered as I read through her records.  Six months before she'd gone in for surgery to replace both of her knee joints due to severe arthritis.  One became infected and they tried antibiotics.  A lot of antibiotics.  Some of which she was, as it now seemed, deathly allergic to.  She got a rare condition in which the top layers of skin separate from those beneath.  She had "toxic epidermal necrolysis" over 90% of her body.  

Your skin is your largest and possibly most important organ in your body.  It keeps in what needs to be in and it keeps out what needs to stay out.  They'd taught us that in medical school.  And the woman I met two days before proved it to be true.  

In the time since she'd developed TENS, she had undergone multiple rounds of bacteria in her blood and low blood pressure and months of ICU care and central venous catheters to deliver more antibiotics and blood pressure medications.  Then her kidneys failed from one of her episodes of low blood flow and she stopped making urine and needed a larger central catheter to be on dialysis.  These catheters got infected along with her blood.  The bacteria that she started growing in her body became resistant to all but the strongest and newest antibiotics that we have.  Then on February 2nd, she'd died.  

She went into cardiopulmonary arrest, or as we say, she "coded," necessitating extreme measures to resuscitate her.  And the resuscitation worked in the sense that her heart restarted and her brain kept the centers that told her body to breath.  But the rest of her brain was gone, having suffered massive strokes as a result of the intervention.  It was like the little babies I'd see who don't get enough air to their brain when they're born.  Sometimes they live for years, but they only know to breath reflexively.

Her skin was the color of a severe sunburn.  And it sloughed off wherever tape or catheters were attached, and even in several places where nothing was attached.  Her hair had almost completely fallen out; what was left was in greasy curly wisps across her scalp.  She was swollen from what I imagine were high doses of steroids to keep her body from attacking its skin and from the large quantities of fluid we'd given her to keep her alive those last few days.  She smelled of infection and we put on the yellow "contact precaution" gowns when we went into her room, not wanted to transmit her infections to ourselves or our other weakened patients. 

That night when we were losing her blood pressure, I called her husband and told him we would need to start medications to keep her blood pressure going.  It was the first time I'd spoken with him but I knew from the chart that he'd had several conversations over the last months about his wife's state of health and her impending death.  The next days he'd planned on moving her to a hospice facility so she could die comfortably.  

To preserve her live that night what I really needed was a large central line--one for pressors and dialysis.  It would be difficult to get on her and it would be painful.  He didn't want to keep trying to perpetuate what remained of her life, however.  I supposed that I could try peripheral pressors, which don't take long to burn through veins and cause longer-term complications which I knew would not be an issue with her.  She was out of "long term" on this earth.  

I offered that to him, only wanting her to make it five more hours to 8 am when she could go to hospice and die comfortably.  I suspected, though, that she would not make it that long.  And I knew she wouldn't unless I gave her those medications. 

It had taken him months to come to terms with the fact that she was going to die and finally, he was ready to let her go.  But I didn't think I could keep her alive much longer.  He'd only recently changed her "code status" to exclude compressions and shocks (she'd had a tracheostomy tube placed months before).  But he said we could still use code medications, which are temporizing at best without the other interventions.  

So I started a pressor peripherally; and it worked for a while, but then we were using as much of it as we could and her blood pressure was still falling.  She started to die at 6 am and I went for the "chemical code," which ended up feeling futile as we stood around her in our yellow mourning dresses and injected epinephrine into her small peripheral lines which made her blood pressure temporarily jump to 210/150 and then trickle back down to 70/30 and keep falling.  I asked the nurses to call her husband as soon as we'd started and fifteen minutes into the code I called him myself from the room.  We'd talked several times by then and I knew he lived far away and had just gotten out of the shower and was planning on being there at 8:30.  We weren't going to last that long. He said it would take him 45 minutes to get there, "depending on traffic," he told me in a steady voice.  I begged him to please drive carefully, unable to truly imagine what he'd gone through those last several months.

I started another intravenous infusion to keep her blood pressure in the alive range until he got there and the nurses needed to give her boluses of epinephrine even with that.  They paged me when he arrived.  

By the time I got down to her bedside, Matt was already there explaining things to him and asking him to put on the yellow gown.  He did a god job--calm and sensitive and thorough.  He'll be a fine doctor.  I stayed back, not wanting to complicate matters more with one more face.  And, not wanting to see the pain in his stoic eyes any closer than I already had.  

He asked Matt if he could kiss her and Matt said yes.  

In the room, he spoke softly to her, telling her he'd tried everything he could to keep her alive, but now it was time to go.  Now she could go.  He kissed her red swollen mouth as her eyes roved purposely around the room.  I don't know what she felt those last moments, if anything.  He asked us to turn off the pressors and start a morphine infusion to ease her pain and calm her labored breathing.  He stayed at her bedside, whispering to her for the next few hours in took for her heart to stop its resilient beats.  

The social work note said her children found it too hard to see her like that.  A family friend was there with him for part of the time.  The social worker himself stayed for much of her slipping away, comforting and listening to her husband.  In his note he said they'd talked of God.  The note ended with him dictating, "I have just been informed that the patient is expiring at this time."  Time of death 2pm.

Ali had been working that night and tears were welling up in my eyes when I got back from the SICU to our medical ICU.  I knew it was time for her to no longer suffer, but her husband was so "dear" with her, as one of the nurses who'd helped code her said.  And soon she would be gone.  Plus I'd been up all night and hadn't eaten since lunch the day before trying to admit two other patients and keep her alive a little longer. I felt wrung out.  He kissed me before he left for breakfast.  I still had to present the patients I'd admitted and finish rounding.  

In debriefing the chemical code issue with the ICU fellow, she told me she didn't even offer pressors through a peripheral line, nor offer purely chemical codes.  They had no long term benefit.  The code had felt ridiculous from a medical standpoint.  I knew it could only end one way and we were simply delaying the inevitable and quickly approaching end.  

But sometimes, maybe delaying is enough.  It made no difference to the patient, who I still believe had spiritually left months ago.  But it made a difference to her husband--he was able to be at her side when she "passed."  He'd told me he wanted to be there.  I didn't stave off death for the dying, but for the living, for them to say goodbye in whatever way they needed.  

It was a hard code for me, really the first I'd "run" alone--long and immediately unsatisfying in its outcome.  But now, days later, as I talked it over with another of our interns, I think I would do the same if I had it to do again, though perhaps ask her husband to come in sooner.  I'd still keep her alive until he got there, if I could.  It's the least I could do.

I think if him hunched over her bed, holding her hand and kissing her face, whispering soothingly in her ear.  Maybe she was there.  Even if she wasn't it was  testament to what she'd been, and what they'd been together.  And what he would have to be without her. 

Death is not a fight we win or lose, though it sometimes feels that way.  And it's hard to meet the end of the known--and hard to send those we love, those with whom we thought we'd grow old, those with whom we'd shared a life off into the unknown away from us and alone.

I wonder if radiologists see people in black and white.

A Daaaay in the Life

Tuesday started off as the prior two days on heme-onc consults had generally started.  I looked up the overnight events on my consult patients before heading to clinic.  I had time to visit one briefly in his neutropenic precaution cave of a room.  He has a new diagnosis of AML at age 77.  He'd refused chemotherapy for days, but he seemed to be changing his mind as the new attending had explained to him, slowly and repeatedly at our 6 pm rounds the day before, the more gentle chemotherapy he could choose which would have a chance of holding the leukemia at bay for a bit longer.  He was in his bed "sleeping," but he'd hope his eyes quickly when I came in and then close them again and not respond to me if he didn't feel like chatting.  The ENT consult note for his lip lesion today used one word to describe him during their visit "annoyed."  

I rushed down to clinic, wondering if it would be like clinic the day before when I did not see a single patient for the entire three hours so instead watched the poor med student get drilled with questions he didn't know the answers to.  The attending did teach us a lot, so that was nice and sometimes I could get him talking about my consult patients long enough for the med student to google answers.

But clinic on Tuesday would be different.  The first patient I picked up had CLL stage 0 and after I'd seem him, the attending told me I shouldn't have, even though his name clearly had the word "resident ok" next to it, which I'd, foolishly I guess, interpreted as meaning I could see him.  But no.  I saw one more patient and then had a nice surprise!  One of my favorite patients, Mr. Jegan, from my intern year had an appointment that day.  I'd seen him waiting and was thrilled when his chart was in the rack for the taking.  Of course, it's not the best thing to be re-referred to heme-onc clinic at the age of 89.  He had a recurrence of his ITP, the same conditions for which he'd been admitted when we met the first time.  In the interim since then he'd been treated with dexamethasone, rituximab, and a long steroid taper which had wreaked havoc on his blood glucose control and made his neuropathy worse.

I remembered him mostly because of his blue sailors cap he always wore.  I later went back to look at the notes I'd written about him two years ago and found that I'd mentioned in there. I remembered his platlets were lower than our machine could measure but he felt well the whole time and kept wanting to go home.  And his wife was there a lot.  They were very endearing together.  And he wore the same kind of paler blue same-color jean pants that Pop used to wear all the time.  He would tease his wife and she would smile at him and go on with her concerns over his health.  She still worked and he got himself around the house pretty well.  He'd put his hand on hers--wrinkled old soft hands entwined companionably and practically. 

He'd grown weaker in the time since I saw him last.  He demonstrated how he had to stand up and his legs shook underneath him.  He was also having worse headaches.  No bleeding that he'd noticed, even though his platlets were 41 (normal above 130).

In addition, he was still on the same blood thinner that I take: coumadin (oval-shaped multi-colored devil pills that they are).  He'd had three separate instances of blood clots in his legs after his knee replacements almost 25 years ago so the was on "lifelong" anticoagulation.  Since his platlets were low, the fellow had called him on the Friday before and asked that he stop the coumadin.  We wanted to get an ultrasound of his legs to see if the clots were still there. He grumbled amiably about that saying it wasn't going to help anything.  

That afternoon, I saw a new consult: a 72 year old Jehovah's Witness (who do not accept blood product transfusions) with the hematologist's perfect storm of clotting/bleeding.  He'd come in for a toe amputation and developed shortness of breath the day after, which prompted cardiac markers with slight indication of heart attack and a relatively normal EKG.  By a few hours later when they repeated the cardiac markers, they had risen and his EKG was showing signs of acute heart attack.  He was started on a blood thinner by vein (heparin) then was rushed to the cath lab where two drug-eluting stents were used to prop open his mostly occluded vessels that take blood to the heart.  With this and evaluation with ultrasound of his heart, they also saw a big clot in one of the main pumping chambers of his heart (mural thrombus).  He was switched to integrillin blood thinner for 18 hours then back to heparin and simultaneously with coumadin to treat the clot in his heart.  And then needed clodigripel and aspirin to keep the new stents in his heart from clotting off.  Then his platlets, which for some as of yet unexplained reason live too low (around 100) began to fall.  And fall.  And fall, which gave him a large risk of bleeding.  So they tried to reverse the coumadin with vitamin K.  And heparin can often cause low platlets so they stopped that also and started him on argatroban, which complicates the transition to coumadin because it alters the test we usually use to see if it's therapeutic.  And then he started having blood in his stools, ie a GI bleed.   What a big confusing mess of confused platlets and clotting cascade in this poor man's body.  And if he started bleeding profusely, he would not take blood transfusions.  

I'm seeing this consult and the attending, who is perhaps the most thorough I have yet met, is going through his information and I know he's going to find more than I can in the short amount of time.  And he does, which if fine, since he's the expert and he spend a lot of time worrying and telling me about special antibody tests we can run to see if it really was the heparin that's the problem and we talk with the cardiologists how need the plavix to protect their stents and the patient's heart and we talk more and we think more and we talk and talk. 

And then we to go tumor board for two hours where they present the lung cancer patients first, who all have grim prognoses and for whom they try to figure out how to at least minimize symptoms.  And then we talk about the other cancer patients and whether surgery or radiation or chemotherapy is the best approach.  Or maybe everything. Or maybe some.  I find it all sad and elusive as they bat around idea about chemotheraputic drugs I don't recognize and flash pictures on the wall of lungs obliterated with cancer.  Or look at the microscope pictures of the malignant cells that have returned.

And then we finish and we still have to round on the inpatient service.  So we talk and talk and think and talk.

Then I get a page about Mr. Jegan's blood clots in his legs.  One of them which had gone away at one point was back.  Crap.  And we had him off of his blood thinner because of his low platlets.  Did we restart it?  Did we switch him to one that was more easily reversible.  Did we need to bring him back in that night to be admitted?  I didn't have the answers, so I asked the heme-0nc fellow.  He wasn't sure later so, fortunately, though it was 7 p.m. by then and we were still working on our notes, our attendings were there--both the one who had seen Mr. Jegan that morning and the thorough clotting specialist.  

The big danger with blood clots in the venous system of your legs is that they'll break loose and get pumped through your heart and end up trapped in your lungs where they block blood flow there and can cause death.  We did not want that to happen to Mr. Jegan.  So we talked and we thought and we worried and we talked.  We ended up calling him and asking him to come in the next day to start intravenous treatment for his low platlets and subcutaneous treatment for his leg clots.

Then I went back to finish my notes.  When I went to the ICU at 8:30 pm to get the most recent vitals on Mr. Perfect-Storm, our attending was still up there talking to him.  While I had learned a lot that day and knew he would probably have something new to share, I was tired and left before he came out of the room.  

Mom was home when I got there.  Bryce is somewhere on his way to Colorado with his friend, Hayden who just spent a couple weeks with us.  I warned her how tired and hungry and grumpy I felt and ate and went to bed, sorry that I'd signed up for moonlighting that night as I set my pager by my bed and switched it from vibrate to sound.  

I laid there for 15 minutes, almost fell asleep when it went off: "Shawna, I have one patient on the floor for you, gastroenteritis, and three in the ER so far. Katy."  What?!  Being called in so early on a week night in April is quite unusual.  And I was so tired!  When I called her back to let her know I was on my way, she was all discombobulated with the speed with which she'd just heard about the 15 new admits in the last 6 hours.  From being on her side, I knew that the beginning of my shift was a relief for her at least since she could pass off the insistent admit pager.  I changed from my pjs to my scrubs, put on my clogs on the way out the door and was glad I had started to keep two white coats in my car, one for my day adult job at the VA and one for my night moonlighting job at Children's (with the heavy otoscope in one pocket and Harriet Lane in the other, it was by far the heavier of the two).  The last few times I'd moonlit, I'd even started taking a blanket and pillow from my bed since I could usually catch an hour's nap in the limo-tinted back seat of my car before having to be back at work at the VA in my other coat. 

There are parts of moonlighting I really like.  And on nights when I'm no so utterly exhausted before I even start, I actually look forward to it.  I like being able to think independently about what to do with the patients.  I like working with the nurses as a team.  I like the relative peace of the hospital at night.  I like the surprise of not knowing what is next.  I like the variety.  I like the challenge of managing so many patients so quickly and I like it when it's a little slower and I can read and think a bit more about the ones that I do get.  I like being the first to see them on the floor and trying to anticipate their hospital course.  I like the experience.  I like the extra funds it provides.  

I don't like doing it when I'm already tired.  I decided I don't like doing it much when I have to work the next day.  I don't like not being there in the morning to see what happens next.  I don't like not getting any feedback from people about the choices I make in the middle of the night, besides what I can glean from their records and discharge summaries.

Anyway, in I went.  I realized on my way there that I'd forgotten my blanket and pillow.  But I had a beach blanket and a fleece in the trunk that would do.  

Donning my pediatric cape, I swooped in to write admit orders at the speed of light.  The charge nurse caught me on my way in and informed me that another one was on the floor. And was I admitting the 6 month old with congenital glaucoma?  And she'd just called in all their on call nurses cause the ER was packed (which I'd seen as I drove in).  I caught up with Katy and she already had five that she knew of either there or shortly arriving (and one she told me about later that's she'd forgotten the first round, the 6 mo with glaucoma).  And so I started admitting.  Priority went to getting all the orders in and I had my routine: 1) patient has arrived to room page from nurse, 2) call nurse to make sure patient looks stable and let her know how long it may be before I get there, 3) get to patient, 4) review ER notes or outside hospital notes, labs and former dictations in the computer, 5) interview patient and family, 6) physical exam, 7) decisions about what to do, 8) tell them what they might expect, 9) write orders, 10) scribble a few reminders of their story on the history and physical form (which will have to be finished and dictated later), 11) NEXT.  Depending on the complexity it takes me anywhere from 30 minutes to an hour per patient, and longer if I have time to review their past information more or fill out their growth chart.  

And so the night went: an 18 month old with gastroenteritis, a 6 month old with congenital acute angle glaucoma, two teenage boys with pneumonia, one recently out of juvenile hall, a four day old with slow heart rate, two babies with increased seizure activity, a 9 year old with a liver transplant that might be failing,  a 9 year old girl with possible small bowel obstruction, another baby with a fever without known source.  Then one more.  

The last one of the night, at 4:30 am, arrives from another hospital just as I get a page about three more in the ER and hope that they won't get a room until after I have passed off the hot-potato pager.  It didn't sound that bad in the report I got: 11 day old with a fever.  We call these "rule out sepsis" or ROS, and baby under a month get the full court press of antibiotics until the cultures from the blood, urine, and spinal fluid are negative for two days.  Pretty standard stuff and the babies usually have a virus and look like a peach while we treat them just in case it's something worse.  

So I was surprised when the nurse stuck her head in as I was finishing up with one of the other patients, "Room 246 is here."  And again a minute later, "She doesn't look good."  Uh oh.  I remember telling Ali on my way in that I hoped I didn't get anyone really sick because I too tired to manage.  I rushed over to the room which was packed with nurses and one worried grandmother.  Running through my head what I'd heard about this baby, "fever, mother with possible syphilis, mother in jail, other prenatal labs normal."  The baby looked bad.  Grunting is never good and she was grunting and mottled (which is when the skin starts to get pale with red blotches).  She was working to breath and the nurses already had extra oxygen on her and her saturations weren't coming up.  And, they informed me as I hurried in, "She has red jelly like stuff in her diaper."  What could it be?  While I was trying to think, I asked for a blood gas to see if she was acidotic and a sugar level.  Her peripheral perfusion was awful as I touched her cold feet so asked them to give her a 20 ml/kg bolus.  I listened to her heart and had trouble hearing it well over her noisy breathing.  He lungs didn't sound wheezy but they didn't sound good either.  I couldn't hear bowel sounds much.  I rifled through her papers from the outside hospital: her spinal fluid looked okay so far, her white blood cell count was high in her blood (possibly sepsis), her chest x-ray was clear, but her heart looked a little big.  I wasn't sure what to make of the red stool yet, so ordered a STAT abdominal x-ray.  And she already had antibiotics in, but no antivirals, so I wanted some of those, too.  She still didn't look any better after the bolus and the VBG came back with a pH of 7.11 (normal is 7.4 and it's very tightly controlled and important).  The x-ray techs still weren't there.  Her breathing was worse if anything.  I checked who the PICU fellow was on that night and it was one of the senior fellows who'd taught me a lot on my month with them.  I paged him and explained the situation and what I'd done.  "She just looks bad," I concluded.  He would come right down.  

When he got there, he wasn't sure what was going on either, but he asked for all the same things I'd already done and said it made him feel worse that that had all been done and the baby still looked so sick.  He took her upstairs to the PICU. He paged me later to let me know they'd intubated her shortly after and that one of the senior surgeons was taking her to the operating room right then to see if her gut was partially dying or dead already.  

I still had to write all of the history and physical forms for the other 10 patients I'd admitted before I needed to pass them off to the other teams at 6:30 am.  I wrote frantically and finished 8/10 before I went to pass them off, which took about 20 minutes.  I then wrote the other two and started dictating them all back to back, talking as fast as I could and marking the dictation priority so they would be in the computer by the time someone needed them that morning.  I ran around putting the finished paperwork in the charts and finally I was finished with the night.  Sigh.

I had been starving for hours so went to the hospital cafeteria, wondering on my way over what percentage of my meals are prepared and/or eaten in a hospital.  Probably 66% at least.  I indulged in hash browns and eggs and sausage with ketchup and then went to my car to sleep a little.  The trick was getting into the back seat before anyone came along and thought I was leaving and waited for my parking place.

I slept for about an hour before my phone alarm startled me awake and I crawled into the front seat and tried to make sure I didn't have any blanket marks on my face before driving to the VA.  

At least there wasn't any clinic that morning.  Just my two patients to visit, review their overnight events and check to see of any new consults.  No consults.  Just as I was about to start my notes for my patients in preparation for rounds, Mr. Jegan showed up and the fellow had to go off to do something then get ready to do a bone marrow biopsy.  He asked if I could see him.  Of course.  

They were glad to see me again, though not as excited to be back so soon.  Since they were there earlier than expected we could get chemotherapy started.  I visited with them and got them set up in the infusion center and let them know I'd come back to see them.  We took guesses at what Mr. Jegan's platlet count would be that day.  I like them.  Their grandkids are lucky to have them.  

I thought about Pop.  He was a great patient.  All the nurses in the hospital loved him.  No matter what was happening, he always had a smile, or a joke, or a friendly word in his warm Rhode Island accent with a big-man's gentle pat of his worn hands.  Even when he was tired or in pain, he hardly complained.  I remember after he'd had his open heart surgery when he was 83 and I stayed with him for hours in the hospital until he could come home and I took care of him there, he was so glad to see me and have company.  He slept part of the time I was there.  I encouraged him to eat.  His doctors and nurses and physical therapists visited.  I bed they thought I was lucky to have him, too. I know I was. 

There are certain people in your life who you just know are good.  All the way good.   People you trust completely with everything that you have.  People who will love you no matter what you do.  Grandparents are special that way.  I was thinking today that we are all allotted a few of those people.  And they are peeled away by age or distance or circumstances and then we are left alone.  Or with memories of them.  And perhaps the ability to meet new ones, but it's not the same as the core people--the first people--the ones who made you who you are and about whom you dream and who you feel even when they're not there.  Those are special people.  

I could tell Mr. and Mrs. Jegan were those kind of people to those they loved the most.  I'd like to be one of their circle, but I'm not and that's the way it should be.  I'm their doctor and that will have to be enough.  At least I'm lucky enough to be in a position to help them and know them in some semi-intimate way.  

So, while waiting for his platelet count to return, I worked more on my notes, went to noon conference cardiology review and then we waited for the attendings to show up and they didn't until late and there was some miscommunication and we looked at blood smears then, and bone marrow smears, and talked and talked and thought and talked.  Then they had to go a meeting that would last an hour and then round after that, at 4 pm.  I was not going to make it that long and we'd already decided what to do with my patients so I asked the fellow if I could go.  I'm not sure if he was happy about it but I was too tired to care.  I'd been working for practically 35 hours in a row and I was too tired to care.  

I stumbled home, changed, put in my ear plugs and fell asleep.  The deep solid sleep of exhaustion.  Dreamless sleep where you wake up in the same position in which you passed out.  Sleep that feels like it could go on forever.  Sleep that only ends when you get too hungry to even lay still or when your bladder reaches critical mass.

I woke up at 9 pm and remembered I was moonlighting again that night and glared at the pager on my night stand, dreaming of the day when I would not have to dread waking up to the harsh "beep beep beep."  And praying that I would not wake up to it later that night.  I got up to go to the bathroom and take my medicines, realizing moments after I swallowed them that I'd taken my morning pills instead of my night pills. Oops, those included the prednisone.  I didn't think the measly two milligrams that I take now would affect my sleep, but it's hard to tell.  I found the cookie jar full of fresh-baked chocolate chip cookies and blessed my mom while eating three of them for dinner with a glass of lactaid milk before stumbling back to bed.  Unable to fall back asleep, I fretted and fumed about nothing, tossed and turned, then read my book, "Hannah's Dream," for a while.  The main character reminded me of Pop again, the way he called those he loved, "Shug" like Pop had always called me.  The pager was still quiet.  

I tossed and turned a while more.  My feet were aching.  Finally I must have fallen asleep.  My pager woke me up, but it was light outside.  I'd survived the night without getting called in.  It was morning and the page was reminding me of our morning teaching conference.  I was pretty sure I was going to be late.  But finally, I wasn't tired.

Hymenoptera--Pollinators--Small Things

When I was up at my brother's place (which used to be my parents' place), a wasp bit me.  Becky had become distracted pulling weeds (and there are always more), and I had finished riding my mom's horse (because mine died while I was in med school). I was dirty anyway and weed-pulling looked like something to do.  A big patch of Johnson grass (it's amazing how the botanical names of childhood return like familiar strangers) waved in the middle of the lavender and poppies that bloomed every year since our 90 year old neighbor had them in her yard (before her elderly son shot her and her sister and then himself--I keep the newspaper clipping in a small diary with flowers on the front).  I told Becky I should get gloves (Pop had soft fancy leather ones he only wore occasionally because they were from his only son who had died of skin cancer just before Pop's 75th birthday).  But I thought I could just pull one up and then get gloves (though the ones with my name on them in black Sharpie ink were in San Diego).  I had barely reached down toward the root when I felt a pain on the fourth finger of my right hand.  A wasp flew out of the clump of grass (just as upset as I was).  My finger went numb and I doubled over for a moment as Colin got home from his job interview and Becky got me ice in a zip-lock bag.  Small Things.

The bees love the flowers in my Mom's front yard.  I felt a little worried walking home barefoot from the high school track today but the grass was so soft and the track so gritty and the pavement so hard.  The bees in the midfield buzzed around the clover as they had in our field as kids.  My brothers used to run as fast as they could to the creek at the end of the field so that the bees wouldn't sting them.  If you move your foot fast enough they don't have time to see you coming.  It worked for them most of the time.  I'd scamper through on the balls of my feet only thinking that less surface area exposed would be best.  That worked most of the time also.  Our feet used to be thick with callouses and strong with un-shoed use.  Small Things.

I finished reading "The God of Small Things" two days ago.  It has "study questions" at the end.  One about why Arundhati Roy ended it the way she did.  The story line is a swirl between present and past, very non-linear--at least in a chronological fashion, but if you redefine the line, it can become linear as well.  It rises between tragedy of reality and figurative reality where the twins, who are "we", read words sdrawkcab (backwards) and worry about their mom loving them a little less and feel the cold feet of their grandfather's moth on her heart.  There are mantras in the book that climax toward the end which is the middle of an hour glass--the narrow part where sand squeezes through.  It is the reaching down of the figurative to meet the reaching up of the literal.  In the middle of Small Things like spider I rescued from the bathtub after I returned from two weeks of vacation and wasps and bees and moths and grains of sand.  Small Things.

"Another world is not only possible, she is on her way.  On a quiet day, I can hear her breathing."   --Arundhati Roy